Rib Fractures + Pulmonary Contusion

EMRAP May 26, 2026

Britt Guest, DO, and Kenji Inaba, MD

Dr. Guest and Dr. Inaba discuss what features of rib fractures require admission or necessitate transfer to a trauma center. 

Criteria to consider when discharging a patient with rib fractures: 

1. Is there something in the pleural space that needs intervention (hemothorax/ pneumothorax)?
2. Is the patient oxygenating well?
3. Is their pain controlled with oral medications?

• Location: Higher rib fractures require more force and should be cautiously evaluated; however, if they meet the same original criteria, the patient may still be able to be discharged. 
• Number of Fractures: There is no absolute number of rib fractures that automatically necessitates admission. A greater number of rib fractures suggests a more significant mechanism of injury and the patient should be thoroughly evaluated. 
• Comorbidities: Older age and underlying pulmonary comorbidities should be factored into the decision to hospitalize patients with rib fractures. Both of these raise the mortality of rib fractures as these patients have less reserve. 
• Pulmonary Contusions: Small pulmonary contusions that do not impede the patient’s oxygenation or pain control can similarly be managed conservatively.
  • You do not need to observe or reimage specifically for concern of “blossoming contusions.” 
• Admission: 
  • What level of care do they need (ward, telemetry, ICU)? Can you provide that level of care at your hospital? 
  • The majority of care is supportive with oxygenation and pain control.
    • They may need transfer if epidurals or regional blocks are required in addition to traditional multimodal pain control. 
  • Do they need evaluation for surgical fixation? If so, transfer to a trauma center. 
    • Flail segment/ flail chest
    • 3+ rib fractures with significant displacement (no overlap)
      •  with pulmonary complications and/or difficulty with pain control 
• Studies examining patient experience with hospital transfer note that there is significant distress and inconvenience in being far away from their home, family, and support. Transferring is not a benign procedure and should be assessed carefully. 

PEARL: Not all rib fractures require admission. If patients do not have a hemothorax/ pneumothorax, are oxygenating appropriately, and have adequate pain control with oral medications, they may be able to be discharged.